Healthcare Provider Details

I. General information

NPI: 1780122150
Provider Name (Legal Business Name): JO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2017
Last Update Date: 02/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N ABINGTON RD
CLARKS GREEN PA
18411-2541
US

IV. Provider business mailing address

120 N ABINGTON RD
CLARKS GREEN PA
18411-2541
US

V. Phone/Fax

Practice location:
  • Phone: 570-479-1626
  • Fax: 570-586-2196
Mailing address:
  • Phone: 570-479-1626
  • Fax: 570-586-2196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW017373
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JENNIFER P ODOM
Title or Position: THERAPIST
Credential: LCSW
Phone: 570-479-1626